01090090 CI nun DIING DPERTONNo PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10838 SYCAMORE DR. URY & BECKY PRIEL 01090090
SANITARY NO. CONTROL NO.
GOO ARCHITEC(ENGINEER: BUILDING PERMIT INFO
u y- BLDG ELECT PLUMB MF.CH
w= LICENSED CONTRACTOR'S DECLARATION ]tib Description
z_G 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
mtw
with Section ELECT OUTLETS, GAS LINE & /
t m y is in full force and cRect.
:c P a License classLie.« SPA.
Data C.moremr
ARCHITECT'S DECLARATION may+
gI understand my plans shall W used as public records <
r s�
i a p O Littmetl Professional
o(Zy Oad I min UILD[R.lire C ATION /
I hereby afnvn ohm 1 1. exempt from the Contents C S License Law for the
I.z following rtasoa(Section]031.5.Businms atd Professions Code:Any city or county
Sa D which requires a pemnit in consumer,alma improve,demolish,or repair,any stmaum
w ca -prior to its issuame,dao requires me,applicant scratch pemmo file a signed satemem, ..... .._. ._
matnmenccembd Section
tdlhe of
Division me Co,Beepr's Licensefawmer Cor) S FI:FIOOCp�� F'+ 15 , aU3IlOn
(commencing with Section i](Xp)of Division3of the Bmi«ss and 09fessiom Cada (.("}^C"s ?i.'•I- I k. r. :ar;�C�.+t.`_4C.�.1�.+ .
or that he is exempt thclehom and the basis for the alldged eadmimim.Any violation I
of Section]031.3 by any applicant fm a permit subjects the epplkant to a ativil penalty
of not marc than five hundred dollars($500). um er Occupancy Type
❑Los owner of Ne prupeny.o my amployas with wages its heir sol.our fa mtimm. �r�a��lsa
will do the work,and the structure is act intended m ofia.d for sal.(sec.1004. `13ai•>0.`lalJ+rKa�" �[l);ERGY .
Business and Prolbssions Code:The Co noo,m's License Law docs nor apply t.an 501 - FINAL Elm [
owner of property Who Wilds or improves thereon,and who doss such work Nmself
or through his own employees.provided that such improvements am not intended or 505 - FINAL ELECTRICAL
ofrem d for We If,however,she Wildmg or impmveme,is sold within one year os
completion,the owner-builder will have the burden of proving that he did not build or
improve for propose of sale.).
f1.is owner of the propen,am exclusively convecting with licensed contractors to
orons,the pmjen(Sec.7004.Business and Pofitomns Code:)The Contnnor's
License Law does not apply m an ow«r of property wh^Wilds m improves thereon, I
and who contracts for such projects with a comemom(s)licensed pursuant to the
Commences uaense Law.
❑1 vat exempt under Se .B k P C fonhis reamn
owntr D t. gl �J I
COMPENSATION RA]lON
I hereby nRnn under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cmificate of Consent to self-insure for Workers
R.' Coropcosmion. us provided for by Section 3700 of the LaWr Cede, for the
' performenax of the work for which this permit u issued. ,
❑1 have ad will maintain Worker's Compensation Imymnce,as report by Section
37M of he U`
`W CMM,for the perform.of the work f«which this pemrit is
issued:My Workers Compensation Insurance canter and Policy number are:
Camt ,ls'1Polis,No. . 't ,,k• •'ys lir..y.J )! a (.� ' �e i'�sf If.. tcj 'i + I,
' CERTIFICATION OF EXEMPTION FROM WORKERS'i, ` '
' COMPENSATION INSURANCE"
(Thi'section need nmt bo completed if the permit is for one hundred dollen `' '' ' s ;j,'
1E100)ar less,)
/. I ceirtity t in theapertt,of rworkwk f« M1icM1 tti prnn t is iss ,1 t
shill t i employ ^Y ce n Y ann se � b) t t the Worseued
n'
Com at JJ..00 f Cpl�orpt pate_ H �J f
APPIP am
NOTICETOAPPIlJJ , L:'If, f4cr making this Certificate of Exemption,you should
z buomc subjca tdOm Workers Comcenation provisions.of the Labor Code,you'muat
Q Q forthwith comply with such provisions or this permit shall be lamed revoked.
y ' • CONS TRUCnON LENDING AGENCY I '•
> 1 hereby aRr{n that Nen is a construction lending agency for the per arro'me !
W of the work for which this permit is issued(Sec.3097•Co,C.)
fed.'Q Lender's Name'
Vz Under.,Address ,
Q 1 unify than I have read this application and W.that the above information is
correct.I agree to comply with all city and .only nolimm.,and state laws relating
Q U to Wilding construction.and hemby auWosin reprasenatives ofmis city to enter upon
r�
the above-mentioned property for inspection purposes.
�.gy (We)ogrcc to save,indemnify and kap harrm.as the City of Cupcnum against
IA) liabilities,judgments,costs and expenses which may in any way accrue against said y
U z City fir.mequcnce of,ha granting of this pnmit. - (� 1 aJO/I�'
Issued by: Date
APPLICANT UNDERSTAND'AND WILL OMPLY WITHAL NON-POINT ( /(r
SOURCE
/ ""': ��—'7Date Re-roofs
HA2ARDOU MATERIALS DISCLOSURE'
Will the applicant orfuture Wilding *.am.«handle likiardndsmveria Type of Roof .- . . .. ..... _.. _,._... ... ..
as refined by the CufserfirsoM- _ pal Cede Chapter 9.1 Z and the Halth and Safety ly pp s r,.•,;, .a tl.f T.., s •s' 1 r '
Code s a n25533(a)1 ., ) e,l kl. 1. ( •. s . r i.l in .. q
t ❑Y. N :,... t ,E..
.. ...All.roofs shall be inspected pnor.[aany roofing material being.ins[alled...
Will the applicant or future building occupant use equipment or devices whim If a roof is installed without first obtaining an inspection;I'agree to°remove
-mit haviAous air contaminants as defined by dt,Bay Arca Air Quality Management
3iiwen all new materials for inspection. Applicant understands and will comply with
-�
Oyer, )lN all non-point source regulations. ,
'�s.�✓ I have mad-flas Knead.mat ;h req .' rits under Chapt 695'of the
Cali, hM1 Safe,, alSections]5505 35577 d 25534.1understand that
dlhcWltl in s gd meseuu a dyh ,robell t@tt y pon'b'I ryt notify the /
occupant of the regmmments Which..It be met poor m hismate of a Cen fee¢of _
Occupancy. .
•• Signatyy Applicant/ Date
owner n,autn^riaea agmr Date All roof coverings to be Class,"B"or better
_1 f OFFICE _ _